119 Gray St — fall

Location: Charlie post

Time: 17:12

Conditions: Clear and warm

Equipment: fully stocked

 

Dispatch

It’s deep into the heart of Scenarioville rush hour. You’ve been sitting at Charlie for almost an hour, enjoying some well-earned rest and jawing with Steve about which mob film is the greatest. He says Goodfellas, but come on — Joe Pesci is an artless character actor, and you can’t respect anybody who takes him seriously. You inform Steve of this and he rebuts with some interesting but anatomically unlikely recommendations for you.

That done, you’re thinking about refreshing your coffee. But then the radio crackles… (click for audio)

[Ambulance 61, 6-1, respond priority 1 to 119 Gray St, apartment 718 for a fall. That’s 1-1-9 Gray St, cross of Endicott Rd, for a conscious, breathing 70-year-old female, still on the floor. With Ladder 1 at 17:13. A61?]

 

Response

Oh well. Steve bounces you out of the parking lot and onto the crowded roadway. Times like this, his 83,016 years working in the city come in handy; he knows the best routes for evading the worst traffic. This time, he chooses Mass Ave — which is busy, but has enough room to squeeze through with your lights on — and cuts down Highland.

As you pull up, you see a large apartment building that you visit occasionally, gray and institutional in appearance. Ladder 1 is stopped out front with a police cruiser. You park in a pull-through by the door, toss a backboard onto your stretcher, pile the first-in, airway, and C-spine bags onto that, and head inside.

The elevator comes, and you eyeball it dubiously. Eventually, you’re able to fit the stretcher, but only by partially elevating the back, which tilts the board and nearly dumps the bags everywhere. You reach the seventh floor and everybody falls out.

Down the hall is room 718. You leave the stretcher outside and bring the first-in bag. Inside you find a living room packed with first responders, only some of whom have showered recently. “In here,” a firefighter points, directing you to the bathroom.

 

Scene

In the bathroom, which is about the size of a double closet, you find an elderly woman lying on her left side upon the tile floor, only a bath mat beneath her. An elderly man is by the door, hovering and looking concerned. The apartment seems generally well-kept, although you don’t see any fixtures in the bathroom for elder safety. In fact, it’s about the right size for a small submarine, which always makes things fun.

 

Initial Assessment

There’s almost no room to stand in the bathroom, but you manage to get inside without stepping on anybody and perch yourself on the edge of the bathtub. Leaning over so you’re within eyesight, you chirp: “Hi!”

Her eyes are open and she easily notices you. “Hello,” she replies in a controlled voice.

With one hand you find her free arm. Her skin is warm and dry, and her radial pulse strong, regular, and unremarkable in rate.

“I’m Sam,” you tell her. “What’s your name?”

“Carol.”

“All right, Carol. What happened?”

“I fell.”

From the door, the man — you presume her husband — says, “She was using the toilet, and she fell.”

 

 

---

 

 

“Did you see it happen?” you ask the husband.

“No, but I heard. I came in and she was on the floor.”

“So you came in right after?”

“Yes.”

“Was she awake like this, or was she unconscious?”

“She was awake. I didn’t want to move her… and I wasn’t sure if I could.”

“Yep, that’s fine.”

To Carol, you ask, “How are you feeling now?”

“My head hurts.”

“Oh, where?”

“On the side.”

She touches the left side of her head. You can’t see it very well since it’s facing the ground, but you reach under and gently palpate. There’s no gross instability, but you can feel a lump, and a trace amount of blood appears on your gloves.

“Okay, anywhere else? How’s your neck and your back?” You palpate them briefly, finding nothing remarkable.

“They’re okay.”

There’s not much room in here, so you ask Steve — who’s loitering by the door — “Can you get some history and meds?” He nods and leads the husband away from the action.

“Do you remember what happened?”

“I was using the toilet. Then I went to stand and I… I tripped on my clothes.”

“So you fell forward? Did you lose consciousness?”

“What?”

“When you fell, do you know if you passed out?”

“I’m not sure.”

“Did you hit your head?”

“I think so, because it hurts.”

“So your head hurts. How are you feeling otherwise? Is anything else bothering you?”

“The floor is hurting my hip.”

“Yes, I bet. Any numbness or tingling in your hands or your feet?”

“No…”

You push your fingers into her hands. “Can you squeeze?” She does, with equal grips bilaterally. You gently pinch her forearms — “Does that feel the same on both sides?” It does. Placing your hands under her feet, you say, “Push against me?” She demonstrates equal bilateral strength in plantar flexion, and then likewise for dorsiflexion and lower extremity sensation. Briefly, you pat down the portions of her thorax, abdomen, and legs you can reach, finding nothing notable. Her breathing is steady and unlabored.

“All right, Carol. Shall we bring you to the hospital?”

“I think so. Should I?”

“Yes, I think so. They can check you out and make sure everything’s okay. Where do you usually go?”

“Memorial Hospital.”

“Okay. What we’d like to do is put something around your neck and lay you against a board, all right? That way we can keep you from moving too much until we know if you’ve damaged anything.”

“All right.”

Standing, you eyeball the situation. Carol is lying on her left side with a rug under her, curled up slightly around the toilet, and there’s really no room in here to straighten her out. There’s just enough room in the hall outside to lay down a board, however.

On cue, Steve appears in the doorway, carrying the C-spine bag and propping a long spineboard against the wall. Reading from a scrap of paper, he quickly recites: “Mild dementia, hypertension, A-fib, CHF, cholecystectomy, past lung cancer. The usual meds.”

“Any blood thinners?”

“No. Well, aspirin.”

You aren’t sure if Steve can tell Rivaroxaban from arroz con pollo, so you’ll take a look, but for the moment, you figure you should focus on the nice old lady on the ground.

 

 

---

 

 

“Okay, let’s do this,” you announce. “We’ll slide her into the hall using the rug, straighten her out and board her there.”

“Collar first?” Steve asks, digging into the bag.

“Uh…” you think. “No, she’s pretty stable like this, if we collar her now we’ll have to chase behind supporting her head.”

Together, you take the rug and evenly slide Carol into the hallway, magic-carpet style. Once there’s room, you size and place a collar, and borrow some firefighters to provide smooth support while rearranging her into a supine posture. This goes well, you log roll her onto a board, run straps across her, and shortly she’s secured. Although you don’t go crazy with it, you take some care to ensure that her chest strap is snug under the armpits, and run the knee strap as a “figure 8” under the feet — you know you’re probably going to end up standing her somewhat in the elevator.

“Stretcher’s outside,” the SPD officer states. You and Steve lift the board and carry her out cautiously. On the stretcher, you secure the head and buckle the straps. Done and done.

“Where to?” asks a firefighter.

“Memorial.”

“Sweet. We’ve got your bags.”

“Thanks guys.” As expected, you have to prop the board upright somewhat to fit in the elevator; you calm and reassure Carol in the somewhat bizarre position until you’ve made it outside. Outside, you load up into the 61, where SFD has replaced your bags (well, tossed them onto the ground anyway).

“Grab some vitals?” you ask Steve. Meanwhile, you take a moment for a slightly more careful physical exam, which reveals nothing new. In particular, her breath sounds are clear and equal bilaterally, and the lump on her head isn’t bleeding at all. Peering at the medlist your partner gathered, you see:

aspirin

verapamil

captopril

hydrochlorothiazide

“140/82,” reports Steve. “Pulse 68. Resp about 20.”

“All right,” you reply. “Let’s boogie. Memorial.”

He slides out, and you’re shortly on your way. Hoping to get Carol off the board sooner rather than later, Steve throws the lights on, but moves judiciously through traffic; crunching into a six-vehicle pile-up won’t get anybody anywhere. You take the time to stuff some padding into voids under and beneath Carol, including a folded thigh cuff in her lumbar space, inflated to her comfort.

“What was your last name, Carol?”

“Cranton.”

“And your date of birth?”

“4/21/39.”

“So that makes you… seventy…”

“Seventy three.”

Good thing she answered, you were bluffing.

You plop into the tech seat and grab the radio to hail Memorial (click for audio).

[Afternoon Memorial, Scenarioville Ambulance 61. We have a 73 year old female who experienced a mechanical fall, struck her head. Now with a small lateral hematoma, no other complaints or injury; no deficits, no anticoagulation, vitals unremarkable, we’ve got her boarded. We’ll see you in about eight minutes; any questions or concerns?]

“Thanks 61, we’ll be waiting. Memorial out.”

You find a blanket for Ms. Cranton, kill the row of lights shining in her eyes, and make small talk for the remainder of the ride. Steve does a tolerable job of avoiding the worst bumps, and soon you’re backing into Memorial. They point you directly into one of their larger rooms, and a nurse comes to take your report (click for audio).

[Hi, this is Ms. Cranton, she’s 73. She was standing after using the toilet and seems like she tripped on her clothes, fell forward. Unwitnessed, but it seems like she bonked the left side of her head, there’s a decent knot there, minimal bleeding. Unclear on LOC, but she was awake a few seconds later when her husband found her. Stayed on the ground until we showed up. Seems to be no other injury, normal neuro exam, mostly doing okay, just wants to get checked out. History of CHF, A-fib, lung cancer way back, slight dementia. I’ll leave her list of meds over here, but you should have most of it, she usually comes here.]

He thanks you, and in moments the doc is checking her out. You help staff log roll her off the board; they’re pretty good about clearing spines ASAP here.

You find her a warm blanket and leave it nearby until they get her changed into a gown. Then you shake her hand, wish her luck, and escape outside with the board. You have some spare collars and blocks, so you’ll be in decent shape.

Steve is dozing in the driver’s seat, so you shake him away and point outward. “Coffee!”

 

Discussion

Diagnosis: contusion with surface hematoma

Person falls, bumps head; is it just a bumped head or more than that? An age old question of EMS.

In this case, it’s just a bumped head. The physical exam was reassuring, the patient had minimal complaints, and there was nothing to suggest a cause for the fall that was medical or otherwise concerning. (Remember, syncope can result from myriad dysfunctions — cardiac, neurological, etc — and all falls are syncopal until proven otherwise. Everybody says they “tripped.”) If she’d been altered at all, a blood sugar would’ve been wise, and we should always make sure to do a decent neurological exam.

In some systems you could get away without spinal immobilization here; she would probably be a candidate for NEXUS or Canadian clearance criteria. And if she’d wanted to refuse transport, that would be reasonable. But in most cases, it’ll be a nominal board-and-collar, easy ride to a local hospital, quick exam (probably, but not necessarily, with imaging), and with luck she’ll be home by dinner.